Provider Demographics
NPI:1285057687
Name:SULLIVAN, KATHLEEN (RN)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 58TH ST W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-5660
Mailing Address - Country:US
Mailing Address - Phone:727-799-7828
Mailing Address - Fax:727-799-1680
Practice Address - Street 1:2380 TIMBERCREST CIR W
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33763-1624
Practice Address - Country:US
Practice Address - Phone:727-799-7828
Practice Address - Fax:727-799-1680
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-22
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11007033363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health